医院预防措施、患者风险因素与艰难梭菌感染风险的关联：一项基于人群的队列研究。
The association of hospital prevention processes and patient risk factors with the risk of Clostridium difficile infection: a population-based cohort study.
作者信息
Daneman N, Guttmann A, Wang X, Ma X, Gibson D, Stukel T A
机构信息
Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada Division of Paediatric Medicine, Hospital for Sick Children, Toronto, Ontario, Canada Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada.
出版信息
BMJ Qual Saf. 2015 Jul;24(7):435-43. doi: 10.1136/bmjqs-2014-003863. Epub 2015 Apr 24.
BACKGROUND
Clostridium difficile is the most common cause of healthcare-acquired infection; the real-world impacts of some proposed C. difficile prevention processes are unknown.
METHODS
We conducted a population-based retrospective cohort study of all patients admitted to acute care hospitals between April 2011 and March 2012 in Ontario, Canada. Hospital prevention practices were determined by survey of infection control programmes; responses were linked to patient-level risk factors and C. difficile outcomes in Ontario administrative databases. Multivariable generalised estimating equation (GEE) regression models were used to assess the impact of selected understudied hospital prevention processes on the patient-level risk of C. difficile infection, accounting for patient risk factors, baseline C. difficile rates and structural hospital characteristics.
RESULTS
C. difficile infections complicated 2341 of 653 896 admissions (3.6 per 1000 admissions). Implementation of the selected C. difficile prevention practices was variable across the 159 hospitals with isolation of all patients at onset of diarrhoea reported by 43 (27%), auditing of antibiotic stewardship compliance by 26 (16%), auditing of cleaning practices by 115 (72%), on-site diagnostic testing by 74 (47%), vancomycin as first-line treatment by 24 (15%) and reporting rates to senior leadership by 52 (33%). None of these processes were associated with a significantly reduced risk of C. difficile after adjustment for baseline C. difficile rates, structural hospital characteristics and patient-level factors. Patient-level factors were strongly associated with C. difficile risk, including age, comorbidities, non-elective and medical admissions.
CONCLUSIONS
In the largest study to date, selected hospital prevention strategies were not associated with a statistically significant reduction in patients' risk of C. difficile infection. These prevention strategies have either limited effectiveness or were ineffectively implemented during the study period.
背景
艰难梭菌是医疗保健相关感染最常见的病因；一些提议的艰难梭菌预防措施在现实世界中的影响尚不清楚。
方法
我们对2011年4月至2012年3月期间加拿大安大略省急性护理医院收治的所有患者进行了一项基于人群的回顾性队列研究。通过对感染控制项目的调查来确定医院的预防措施；调查结果与安大略省行政数据库中患者层面的风险因素和艰难梭菌感染结果相关联。使用多变量广义估计方程（GEE）回归模型来评估选定的研究较少的医院预防措施对患者层面艰难梭菌感染风险的影响，同时考虑患者风险因素、基线艰难梭菌感染率和医院结构特征。
结果
在653896例入院患者中，2341例（每1000例入院患者中有3.6例）出现了艰难梭菌感染并发症。在159家医院中，选定的艰难梭菌预防措施的实施情况各不相同，43家医院（27%）报告对所有腹泻患者立即进行隔离，26家医院（16%）对抗生素管理合规情况进行审计，115家医院（72%）对清洁措施进行审计，74家医院（47%）进行现场诊断检测，24家医院（15%）将万古霉素作为一线治疗药物，52家医院（33%）向高级领导层报告感染率。在对基线艰难梭菌感染率、医院结构特征和患者层面因素进行调整后，这些措施均未与艰难梭菌感染风险的显著降低相关。患者层面的因素与艰难梭菌感染风险密切相关，包括年龄、合并症、非择期入院和内科入院。
结论
在迄今为止规模最大的研究中，选定的医院预防策略与患者艰难梭菌感染风险的统计学显著降低无关。这些预防策略要么效果有限，要么在研究期间实施不力。
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